Prostate Cancer and Nursing Care

Prostate Cancer,Pathological Demographics of Prostate,Health Outcomes and Quality of Life in Prostate Cancer,Malignancy of Prostate Cancer,Medical Research and Endemics to Prostate Cancer,Prostate Cancer and Nursing Research Topics,Nursing Research on Prostate Cancer,Subjective Description about Prostate Cancer,Prostate Cancer Screening 

Prostate Cancer

    Prostate cancer is the most prevalent visceral cancer in men in the
United States; some 1.3 million men now live with it (American Cancer Society,
2003b). It has been estimated that 70% of men who survive to 80 years of age
have evidence of histologic or latent prostate cancer (Pienta & Esper,
1993). 

    Some researchers, and a great many clinicians and their patients,
believe histologic prostate cancer eventually leads to clinically evident
cancer (Pienta, Goodson, & Esper, 1996). Thus, in an effort to influence
the natural history of prostate cancer, intensive screening efforts dominated
by the use of prostate-specific antigens (PSA) in the past 2 decades have led
to the diagnosis of scores of asymptomatic, latent cancers. 

    These efforts have
resulted in reports of both increased incidence and prevalence of prostate
cancer (Newschaffer, 1997), accounting for a doubling of incidence of prostate
cancer in the US in the 10-year period from 1984 to 1994 (Parkin, Pisani, &
Ferlay , 1999).

Pathological Demographics of Prostate 

    Approximately 80% of the 220,900 men diagnosed with prostate cancer
in 2003 will learn that they have locally confined disease early-stage prostate
cancer (Jemal et al., 2002). Therapeutic alternatives for early-stage prostate
cancer include radical prostatectomy, external beam radiotherapy,
brachytherapy, cryosurgery, and observation (“watchful waiting”). 

    Although
approximately one third of patients with early-stage prostate cancer elect
radical prostatectomy, none of the active treatments has been shown to offer a
survival advantage over observation, although an interim analysis of one trial
suggests a small reduction in prostate cancer specific efficacy but not overall
mortality (Harris & Lohr, 2002; Holmberg et al, 2002). 

    Moreover, each of
the active treatments, including radical prostatectomy, is associated with
physical side effects, including urinary, bowel, and sexual dysfunction, which
may have substantial effects on quality of life.

Health Outcomes and Quality of Life in Prostate Cancer

    Most research on “quality of life” outcomes in early prostate
cancer has focused on the often-problematic side effects of active treatment,
including urinary, bowel, and sexual dysfunction (Talcott et al., 1998). 

    Recent
prospective studies have shown that after brief declines, generic measures of
quality of life return to baseline levels by 12 months after primary prostate
cancer treatment. 

    However, for some, urinary and sexual dyes function may
persist indefinitely, accounting for varying levels of psychological distress
related to changes in masculine identity, stigmatization, or demoralization (Powel,
2002; Clark, Rieker, Propert, & Talcott, 1999; Pirl & Melo, 2002).

Malignancy of Prostate Cancer

    Prior to the PSA era prostate cancer was a malignancy often
detected only in late stages, and associated with imminent death (Litwin,
1994). In the past 20 years the proportion of late to early-stage disease has
shifted dramatically. 

    Recent findings indicated that there has been a
significant reduction in the incidence of metastatic stage disease at
diagnosis, and men are being diagnosed at an earlier age. These findings have
supported the emphasis on local treatment (ie, radical prostatectomy and
external beam radiotherapy), for which the S-year survival rate approximates
100%. 

    However, the survival curve declines with longer follow-up, with 54% of
those determined to be at low risk of recurrence (risk derived from initial
PSA, Gleason score, and clinical stage) recurring by 15 years (D’Amico et al.,
1998). 

    The mean onset of clinical metastasis (eg, symptomatic skeletal
metastasis) corresponds to Gleason score; those men with Gleason scores of less
than 8 having a 27% chance of disease progression at 5 years after biochemical
recurrence, whereas men with Gleason scores of 8 to 10 have a 60% chance of
clinical metastasis at 5 years (Pound et al., 1999; Kupelian, Elshaikh, Reddy,
Zippe, & Klein, 2002). 

    Thus, while intensive screening has led to the
diagnosis of earlier stage disease and improved local therapy, many are left
with lifelong physical consequences of primary treatment, and recurrence is
increasingly common within 5 years. Thus, prostate cancer represents a
significant health problem.

Medical Research and Endemics to Prostate Cancer

    Medical research is addressing many of the clinical challenges
endemic to prostate cancer management. 

    Research that is underground relates to
the genetic predisposition of prostate cancer and mechanisms of carcinogenesis,
updates in the screening of prostate cancer, improved imaging techniques,
recent advances in the technical aspects of local therapies, the use of
nomograms to predict outcome probabilities, advances in hormonal. 

    Treatment for
prostate cancer, including mechanisms potentially useful in reducing the risk
of prostate cancer, the role of dietary and complementary therapies in prostate
cancer, the role of chemotherapy in the treatment of hormone-refractory
prostate cancer, and the integration of bisphosphonates, radioisotopes, and
radiation therapy in the treatment of bone metastasis. 

    While these studies
represent impressive strides, other clinical concerns are not well studied.
With an estimated 380,000 new cases of prostate cancer expected by 2025,
research conducted by nurses over the next few decades is warranted.

Prostate Cancer and Nursing Research Topics

    In an Index Medicus search of manuscripts on prostate cancer
written by nurses, 170 articles were found from 1974-2003. Of these, 45 were
reports of original research on 16 different topics, including: 

    cancer related
fatigue (2), complementary/alternative care (1), coping (2), couples (6),
culturally sensitive care (1), decision making (3), spirituality (2), men’s
concerns (2), quality of care (2), quality of life (7), screening (6),
sexuality (1), survivors (1), treatment outcomes (5), uncertainty (1), and
watchful waiting (2).

Nursing Research on Prostate Cancer

    In essence, nursing research on prostate cancer has focused on
screening of high-risk individuals and effects of local therapy, including
feelings of uncertainty, impact on quality of life, and impact of prostate
cancer on couples. 

    Two themes were common to many of these reports: (1)
patients do not receive sufficient information to make informed decisions about
treatment, and (2) patients are infrequently asked about their experiences
related to prostate cancer and its treatment.

    Several studies found that men have a poor understanding of
prostate cancer and its treatment, what conditions to expect after treatment,
and how to manage postoperative symptoms and the emotional consequences of
primary treatment. 

    Investigators addressed this issue at various time points in
the treatment experience just after diagnosis, while waiting for surgery or
radiotherapy, and immediately postoperatively. While several studies
interviewed only men, others included a spouse or partner in the interview
either individually, as a dyad, or both. 

    The studies that interviewed men
typically focused on the impact of physical changes men experienced after local
therapy, whereas those that included couples addressed concerns that were
slightly different. 

    For example, in one study couples expressed the need to
readdress their marital relationship after the illness as well as a cohesive
message from the couple about how much information they would share with others
about the cancer (Gray, Fitch, Phillips, Labrecque, & Klotz , 1999). In
another study, couples were concerned with how to cope with the changes and the
uncertainty of their future (Harden et al., 2002). 

    Three intervention studies
used psychological distress as an outcome of insufficient information to
increase information sharing that was consistent with the subject’s interest
and decision making style. 

    All showed decreased psychological distress as a
result of information related interventions (Davidson, Goldenberg, Gleave,
& Degner, 2003; Johnson, J., Fieler, Wlasowicz, Mitchell, & Jones,
1997; Johnson, J., 1996).

Subjective Description about Prostate Cancer

    When an investigator takes the time to ask about patient’s
experiences, patients tell them. The problem is that they are not being asked
very often. When they are asked, they do not often feel as if their concerns
are legitimate. 

    Indeed, several papers articulated the value of in-depth
interviewing as a method of ascertaining sensitive information from men
regarding feelings about changes in physical function following primary
treatment and the impact it has had on their relationships and lifestyle. 

    This
concern was also apparent in two studies focusing on measuring cancer-related
fatigue, a particularly distressing problem for men with recurrent disease.
They found that dimensions of fatigue, particularly as it related to patients
with metastatic cancer, had not been well articulated. 

    The investigators
recommended that more time be spent on extrapolating meaning from people’s
experiences rather than being so quick to measure them with instruments that
assess cancer related fatigue and therefore may not include all of the
attributes that patients experience.

Prostate Cancer Screening 

    In addition to the papers that related to these themes, Weinrich and
colleagues” (2004) mention impressive program of research in prostate cancer
screening warrants. These investigators have focused on screening in African
American men in whom prostate cancer is disproportionately present, as well as
rural low- and middle-income men. 

    They have crafted population specific
interventions that have improved screening by attempting to understand barriers
as well as what motivates individuals to participate in screening.

    The nature of the concerns that men with prostate cancer describe
warrants attention by nurse researchers. Given the recent evidence on prostate
cancer screening, researchers will be challenged to help interpret these
findings in a way that informs men’s choices. 

    Treatment choices are incredibly
complex and thus studies that address the information gap that men have
articulated must be addressed. The physical consequences of primary treatment,
such as urinary incontinence and erectile dysfunction, often invoke difficult
behavioral, emotional, and interpersonal changes that are poorly understood and
therefore require attention. 

    A clearer understanding of the emotional and
physical issues related to cancer recurrence is necessary in order to provide
appropriate care to men who face recurrent prostate cancer. To date much of the
research conducted by nurses has been descriptive or exploratory; additional
research is needed.